Gastrointestinal Cancers Flashcards
What are the various types of cancers (with respect to organs) in the GI tract?
Oesophageal cancer Gastric cancer Colorectal cancer Cholangiocarcinoma Hepatocellular carcinoma Pancreatic carcinoma
What are the various prognoses (5YS) for each type of cancer?
Oesophageal - <10% Gastric - <20% Colorectal - (stage B/C) 64-38% (D 3%) Cholangiocarcinoma - no full data Hepatocellular - no full data Pancreatic carcinoma - inoperable 1% (<6m life expectancy), operable 15%
What histological type of gastric cancer is most common?
Adenocarcinoma
How do patients with gastric cancer present?
Dyspepsia Early satiety Nausea/vomiting Weight loss GI bleed Fe deficient anaemia Gastric outlet obstruction
What are the risk factors for gastric cancer?
Diet
Genes
Smoking
H pylori
Family history
Previous gastric resection
Biliary reflux
Premalignant gastric pathology
What are the symptoms/signs for gastric cancer?
Early satiety Dyspepsia Nausea/vomiting Iron deficiency, anaemia Gastric outlet obstruction
What are the alarm features for GI cancer?
Anaemia Loss of Weight Anorexia Recent onset of progressive symptoms Malaena/haematemesis Swallowing Difficulty
What investigations might be done in suspected gastric cancer?
Endoscopy
Contrast Meal
CT chest/Abdom for TNM
What is the process of managing suspected gastric cancer?
Endoscopy and biopsy for histological diagnosis.
Staging
MDT - fitness for treatment options
(surgical vs chemo)
What are the surgical options in gastric cancer?
Subtotal gastrectomy
Total gastrecyc and Roux en Y reconstruction
Laparoscopic distal gastrectomy
Open gastrectomy
What is the most common type of colorectal cancer?
95-98% adenocarcinoma
2/3rds colonic, 1/3rd rectal
What are the risk factors for colorectal cancer?
FH
IBD
Genetics
- FAP, HNPCC, Peutz-Jeghers
Most (85%) are sporadic
- increased age
- male
- previous adenoma/CRC
- diet, obesity, lack of exercise, smoking, DM
The activation of what oncogenes/loss of what tumour suppressors can turn an adenoma into a carcinoma?
Oncogenes
- K-ras
- C-myc
Tumour suppressors
- APC
- p53
- DCC
General DNA repair pathway genes
What are the symptoms/signs of colorectal cancer?
Change in bowel habit/continence
Bleeding
Pain (poorly localised)
Non-intestinal manifestations (investigate if >60yo, or 40 if multiple)
What investigations might be done in suspected colorectal cancer?
Colonoscopy
- biopsy/therapeutic (polyp removal)
- sedation needed, perforation risk
Barium enema
Virtual CT colonography
CT abdo/pelvis
MRI (+ guided colonoscopy)
What is the purpose and method of population screening for colorectal cancer?
Detect pre-malignany adenomas early
Faecal occult blood test
Faecal immunochemical test
Endoscopic investigations
Scottish bowel screening programme
- 50-74yo
- FOBT every 2 years
- +FOBT? Colonoscopy
How may colorectal cancer be treated?
Surgery is basis of therapy ((80% of patients)
- endoscopic/local resection for minimally invasive cancers
- stoma formation (permanent or temporary)
- removal of lymph nodes for histological analysis
- partial hepatectomy for metastases
Chemo
- Dukes C and possibly B
- if +ve lymph node histology
- 5-fluorouracil
Radiotherapy
- rectal only
- with/without chemo to control primary tumour prior to surgery
Palliative for advanced disease
- chemo
- colonic stenting
What are the various stages of Dukes’ criteria?
A - confined to mucosa
B - extended through mucosa to muscle
C - lymph node involvement
D - distant metastases
What is the rough prognosis (5YS) for colorectal cancer?
Dukes A - 83%
Dukes D - 3%
What is bowel anastomosis? What are key aspects to its success?
Attachment of two previously distant portions of bowel after resection
Tension free
Well perfused/oxygenated
Clean surgical site
Acceptable systemic state
What are risk factors for cholangiocarcinoma?
Primary sclerosing cholangitis Congenital cystic disease Biliary-enteric drainage Thorotrast Hepatolithiasis Carcinogens
What are the symptoms/signs of cholangiocarcinoma?
Obstructive jaundice
Itching
Non-specific symptoms
What investigations might be done in suspected cholangiocarcinoma?
Usual lab tests Radiology - USS/EUS, CT - magnetic resonance angiogram - MRCP/ERCP, FDG-PET, cholangioscopy
How is cholangiocarcinoma treated?
Surgery only potential curative option
- the only option in intrahepatic cholangiocarcinoma
Surgical bypass Stenting Palliative radiotherapy Chemo Photodynamic therapy Liver transplant (not standard)
What are the symptoms/signs of hepatocellular carcinoma?
Decompensation of liver disease
Abdominal mass/pain
Weight loss
Bleeding (from tumour)
What investigations might be done in suspected hepatocellular carcinoma?
Tumour markers - AFP
Radiological tests
Liver biopsy done rarely
What are the treatment options in hepatocellular carcinoma?
Hepatic resection
Liver transplant
Chemotherapy
- local (TACE) or systemic
Ablation
- alcohol, RFA
Sorafenib (TKI)
Tamoxifen
What are the different types of oesophageal cancer? Where do they mostly occur?
Adenocarcinoma - distal oesophagus
- obesity
- GORD, Barrett’s
Sqaumous cell carcinoma
- Proximal/Middle oesophagus
- smoking/alcohol
- low socio-economic status
How does oesophageal cancer present?
Progressive dysphagia (90%) Anorexia/weight loss (75%) Odynophagia Chest pain Cough Pneumonia Vocal cord paralysis Haematemesis
Usually presents late
- have commonly spread to regional nodes/liver
What investigations might be done in suspected oesophageal cancer?
Endoscopy/biopsy
Staging using CT/EUS/PET/Bone scan
EUS for TN staging
PET CT for M staging
What are the treatment options in oesophageal cancer?
(Metastatic = unfit for surgery, so palliative care)
Only potential cure is oesophagectomy with/without adjuvant/neoadjuant chemo (5YS 30%)
Require nutritional support
What are the risk factors for pancreatic carcinoma?
Smoking
Chronic pancreatitis
Adult onset DM
Hereditary
75% are duct cell mucinous adenocarcinomas (pancreas head most common site)
Symptoms/signs of pancreatic cancer?
Upper abdominal pain Painless obstructive jaundice Weight loss (90%) Anorexia Fatigue Diarrhoea/steatorrhea Nausa/Vomiting Tender subcutaneous fat nodules Ascites, portal hypertension Diabetes Recurrent pancreatitis]
What might you find on examination of someone with pancreatic cancer?
Hepatomegaly Jaundice (obstructive) Andominal mass/tenderness Ascites/splenomegaly Supraclavicular lymphadenopathy Palpable GB (with ampullary carcinoma)
Presence of these (except GB) usually indicate unresectable tumour
What investigations might be done in suspected pancreatic cancer?
Usual imaging (US, CT, MRI, XR)
Blood test Laparoscopy + Lap USS Peritoneal cytology PET Tumour markers (CA19-9)
Jaundice - ERCP
Mass with no jaundice
- EUS/percutaneous needle biopsy
Treatment options in pancreatic cancer?
Majority are advanced at presentation, only 10% operable
Radical surgery
- Whipple’s (only if fit, tumour <3cm, no mets)
- PPPD alternative
Palliation of jaundice
- palliative bypass vs ERCP or PTC stenting
- duodenal obstruction (bypass vs stent)
Pain control
Chemo
What is the prognosis in pancreatic cancer?
Inoperable survival <6months (1% 5YS)
Operable 15% 5YS, 30-50% if tumour is ampullary
